| NPI | 1336505429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363AM0700X Physician Assistant, Medical |
| Additional Taxonomies | 133V00000X Dietitian, Registered (Licence: MN 3591) |
| Enumeration Date | 2016-01-06 |
| Last Update Date | 2024-03-25 |